Action Plan to Recognize Preeclampsia and Prevent Eclampsia · PDF fileCalls nursing triage...
Transcript of Action Plan to Recognize Preeclampsia and Prevent Eclampsia · PDF fileCalls nursing triage...
ACTION PLAN TO RECOGNIZE PREECLAMPSIA AND PREVENT ECLAMPSIA
R A C H E L W O O D A R D , M S N , R N C - O B
I O W A S T A T E W I D E P E R I N A T A L C A R E P R O G R A M
Iowa State Conference
October 26, 2015
DISCLOSURES
I have nothing to disclose that
would create a conflict of
interest
1)Analyze and
interpret patient
data from
selected case
study
2)Demonstrate the
application of a
preeclampsia tool
kit.
CASE STUDY
• 29 year old G3 P1 @ 29w6d
• History of chronic hypertension
• Previous OB history of preeclampsia
with severe features with NSVD
delivery at 35 weeks
PATIENT HISTORY
PLAN
• Discuss risk of developing PET
• Patient d/c labetalol continue 25mg Atenolol
• Monitor for growth restriction
• Continue ASA
• Weekly NST beginning at 32 weeks
• Delivery in the 39th week of gestation
Severe Nausea and Headaches, concerning for migraines
Plan:
-Use Fioricet PRN.
-previously referred to neurology for chronic management of headache.
PATIENT HISTORY
Obesity- Class 2 BMI 41 (201 lbs., 5ft2in)
Plan:
• recommend <15lb weight gain this pregnancy
• discussed importance of diet and exercise in pregnancy
PATIENT HISTORY
Solitary kidney
-s/p laparoscopic left nephrectomy in 2003
Plan
• Nephrology consult revealed a healthy kidney by both blood tests and US
• Baseline creatinine 0.9 - continue to monitor monthly throughout the pregnancy
PATIENT HISTORY
Depression/Anxiety
Herpetic Whitlow
Plan
• Continue Fluoxetine and Diazepam (previously counseled on risks)
• Referred to women's wellness clinic -continue mood checks
• Continue acyclovir 800 mg daily
PATIENT HISTORY
Palpitations
Subclinical hypothyroidism
Plan
• -EKG and Maternal echo WNL with EF 59%, normal LV wall thickness
• Cardiology diagnosed her with exercise intolerance. No clear etiology. Recommend blood pressure control at this time.
• TSH 3.18, was recommended to start Synthroid 50 mcg,
PATIENT HISTORY
Baseline studies
• 24 hour urine
protein 220mg
• AST/ALT 17/15
• HCT:39 Plt 282
• Cr.0.9
• Continue daily
prenatal vitamin
• Tdap vaccine to
be administered
between 27-36
weeks gestation
• Declined
influenza vaccine
PRENATAL CARE
PRENATAL VITALS WEIGHT AND ULTRASOUND RESULTS
Weeks Blood pressure Weight
7w1d 142/83 mmHg 91.4 kg
11w1d 147/89 mmHg no weight gain
14w3d 148/91 mmHg 91.8 kg
18w1d 143/91 mmHg 91.3 kg
20w1d 134/80 mmHg 91.9 kg
23w3d 122/67 mmHg, 93 kg , EFW:591gm (50%)
136/74 mmHg,
27w1d 139/98 mmHg 97.3 kg, EFW 959gms(41%)
Calls nursing triage with headache from sinus infection
Goes to Quick Care
• Has headache
• Right upper quadrant pain
• SOB
• B/P 180/120
Receives z-pack and albuterol inhaler
ARRIVES IN EMERGENCY DEPARTMENT
G3 P1
29w6d
• Acute Severe
URQ pain
• Head ache
• Blurred
vision
• SBP >200
Transferred to Labor and Delivery
Temp 36.5
HR 80
RR 20
B/P 191/118
TIME
1819
FHR
141
HR 67
B/P 196/97
MD called to bedside
BMTZ given
IV access obtained
Labs drawn
Headache
Blurred
vision
Agitated
FHR
141-
150
1834
1849
1902
40 sec
seizure
Patient rolled to right
side, oral suctioning
done O2 applied via
non re breather face
mask at 10L/min.
MD at bedside
Anes paged 911
Magnesium
Sulfate 4 gram
bolus
1908
60-70
• HR 84
• B/P 196/84
• 20 mg Hydralazine given IVP
Decision to not go to OR until FHR stable.
1922
Fetal heart tones 135 with minimal variability. Patient calm but
remains disoriented. HR 111, B/P 149/59
1925
75 sec
seizure
Patient rolled to right
side, oral suctioning
done O2 applied via
non re breather face
mask at 10L/min.
Magnesium
Sulfate 2 gram
bolus
1941
Primary LTCS
delivery
1026 gm male
Apgars 1,7.
Cord gases
art.6.92
venous 6.91.
EBL 1000.
BUNDLES AND TOOLKITS
HYPERTENSION AND PREECLAMPSIA
BUNDLE
Weeks Blood pressure
7w1d 142/83 mmHg
11w1d 147/89 mmHg
14w3d 148/91 mmHg
18w1d 143/91 mmHg
20w1d 134/80 mmHg
23w3d 122/67 mmHg
27w1d 139/98 mmHg
25mg Atenolol
Calls nursing triage with headache from sinus infection
Goes to Quick Care
• Has headache
• Right upper quadrant pain
• SOB
• B/P 180/120
Receives z-pack and albuterol inhaler
Sudden increase in
B/P
Headache, epigastric
pain, SOB
QUICK CARE ASSESSMENT
What is it
Why should you care
What should you pay attention to
What should you do if you have signs
Multiple teaching strategies
to accommodate a variety
of cognitive, psychological,
and physical factors that
affect learning
Messages need to be
repeated to be learned
PREECLAMPSIA EARLY RECOGNITION TOOL
C/O headache and blurry vision. Severe right upper quadrant
pain. Patient agitated. Labs : AST 74 ALT 40 HCT 36, PLT 215, PT 9 PTT
25 INR 0.9, CRT1.3.
HR 67, B/P 196/87
23w3d 122/67 mmHg, 93 kg ,
EFW:591gm (50%)
27w1d 139/98 mmHg 97.3 kg,
EFW 959gms(41%)
PREECLAMPSIA EARLY RECOGNITION TOOL
Second RN at bedside, MD called to bedside due to patient
c/o and blood pressure. In- person evaluation
ECLAMPSIA ALGORITHM
Call for help
Magnesium Sulfate 4-6 gram IV loading dose over 15-20 minutes followed by a 2 gram/hr maintenance dose
1.Position patient in left lateral decubitus positon
2. Establish open airway and maintain breathing
3. Check oxygen level
4. Check blood pressure and pulse
5. Obtain IV access: 1 or 2 large bore IVs
Patient begins to have seizure. Patient rolled to right side, oral suctioning done
o2 applied via non re breather face mask at 10L/min. Staff OB at bedside
anesthesia paged 911. Magnesium Sulfate started at 4 grams over 30 minutes
1908 vital signs HR 84, B/P 196/84
SEIZURE
If patient seizes again while on magnesium sulfate maintenance
dose
.Maintain airway and oxygenation
Give a 2nd loading dose of Magnesium sulfate 2 grams over
5 minutes.
Observe for signs of magnesium toxicity
Patient has another seizure that last75 sec. Interventions
done and 2 gm Magnesium bolus given.
RECURRENT SEIZURE AFTER 2ND LOADING DOSE
Re
cu
rre
nt
Se
izu
res
Midazolam
1-2 mg
Lorazepam
4mg
Diazepam
5-10mg
Phenytoin
1000mg
RESOLUTION OF SEIZURES
Maintain Magnesium Sulfate until 24 hours
after last seizure or after delivery, which ever is the
later
Assess for any signs of neurologic injury head
imaging should be considered if neurologic
injury is suspected
Once patient is stabilized preparations should e
made for delivery mode of delivery dependent upon
clinical circumstances
POST DELIVERY CARE TO SNICU AFTER DELIVERY INTUBATED X 24 HOURS.
Continue Magnesium at 2g/hr for 24 hours after delivery
HELLP labs q4 hours overnight
If altered mental status when extubated or persistent severe headaches, consider MRI head with flair to evaluate for PRES.
PRN Hydralazine or Labetalol for systolic >160, diastolic >110.
H/H in AM
Fundal checks per LDR nursing
OVERNIGHT IN SNICU
Overnight on POD#0
Hypotensive and hgb was found to be 7.4 from 12.3 pre-op.
Started on pressors and given 2 units of PRBCs with appropriate rise in Hgb.
0100 ICU MD notified that SBP 90 (91/45) fluid bolus given.
0215 BP continued to drop B/P 77/35, 75/54, 71/40
0340 OB contacted and at bedside due to abdominal distention and tenderness. SBP 80’s
Extubated on POD#1
On POD#2 a CT scan was performed with findings of a rectus sheath hematoma
which was managed conservatively and her hemoglobin was stable thereafter.
Transferred out of the SNICU on POD#3
required several BP medication changes and IV medications for severe range BPs.
On POD#4 she continued to have severe range pressures and renal was
consulted. Her BPs improved with medication changes
Discharged to home on POD#6 on lisinopril 5mg daily, atenolol 50mg BID and
HCTZ 25mg daily.
DISCHARGE INSTRUCTIONS
T Y P I C A L P E T S P E C I F I C
Need to include:
Monitoring B/P at home
Call MD for:
B/P>______
Severe HA or dizziness
Upper right quadrant pain
Visual changes
SOB
Weight gain more than 3lbs in 3days
Maurice L. Druzin, MD; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN;
Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia
(California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed
under contract #11-10006 with the California Department of Public Health; Maternal, Child and
Adolescent Health Division; Published by the California Maternal Quality Care Collaborative,
November 2013. errata5.13.14